1. No category

Regence
Medicare Advantage Policy Manual
TOPIC: Non-Contact Ultrasound Treatments for Wounds
Section: Medicare Manual – Medicine
Approval Date: February 2015
Policy No: M-MED131
Published Date: 05/01/2015
IMPORTANT REMINDER: The health plan’s Medicare Advantage Medical Policies are
developed to provide guidance for members and providers regarding coverage in accordance
with the member Evidence of Coverage (EOC) booklet. Benefit determinations are based in all
cases on any applicable EOC language and any applicable CMS policy. To the extent there
may be any conflict, applicable EOC language or applicable CMS policy take precedence over
the health plan’s Medicare Advantage Medical Policy.
MEDICARE MEDICAL POLICY CRITERIA
CMS Coverage Manuals
None
National Coverage
Determinations (NCD)
None
Noridian Healthcare Solutions
(Noridian) Local Coverage
Determinations (LCD) and
Articles (LCA)
None
Medical Policy Manual
Non-Contact Ultrasound Treatments for Wounds,
Medicine, Policy No. 131
NOTE: Non-contact low-frequency ultrasound is
considered to be investigational for all indications. For
Medicare Advantage, experimental (i.e., investigational)
services are considered not medically necessary as they
have not yet been proven to be safe and effective based
on peer reviewed scientific literature [see the Medical
Policy Development Process and LCD for Non-Covered
1 - M-MED131
Services (L24473)*].
*Noridian LCD for Non-Covered Services (L24473) can be
found on the Medicare Coverage Database website. Enter
the LCD number “L24473” into the Document ID search
field. The database search engine will automatically
request a date of service to ensure the correct version is
selected. Select the appropriate result based on the
following contractor name and number assignments:
 Idaho = Noridian Healthcare Solutions, LLC (02102)
 Oregon = Noridian Healthcare Solutions, LLC
(02302)
 Utah = Noridian Healthcare Solutions, LLC (03502)
 Washington = Noridian Healthcare Solutions, LLC
(02402)
REFERENCES
None
CROSS REFERENCES
Electrostimulation and Electromagnetic Therapy for the Treatment of Wounds, DME, Policy
No. M-83.09
CODES NUMBER DESCRIPTION
CPT
97610
HCPCS
None
Low frequency, non-contact, non-thermal ultrasound, including
topical application(s), when performed, wound assessment, and
instruction(s) for ongoing care, per day
2 - M-MED131